Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Your Rights While A TRICAREHospital Patient
You have the right to receiveall the hospital care that is necessary for the proper diagnosisand treatment of your illness or injury. According to Federal law, yourdischarge date must be determined solely by your medical needs,not by “Diagnosis Related Groups (DRGs)” or by TRICARE payments.
You have the right to be fullyinformed about decisions affecting your TRICARE coverage and payment ofyour hospital stay and any post-hospital services.
You have the right to requesta review by a TRICARE Regional Review Authority (RRA) of any written noticeof noncoverage that you may receive from the hospital stating thatTRICARE will no longer pay for your hospital care. RRAs employ groupsof doctors under contract by the Federal Government to review medicalnecessity, appropriateness and quality of hospital treatment furnishedto TRICARE patients. The phone number and address of the RRA foryour area are:
Contractor's Address
Contractor's Toll-FreeTelephone Number
Talk To Your Doctor AboutYour Stay In The Hospital
You and your doctor know moreabout your condition and your health needs than anyone else. Decisionsabout your medical treatment should be made between you and yourdoctor. If you have any questions about your medicaltreatment, your need for continued hospital care, your discharge,your need for possible post-hospital care, don’t hesitate to askyour doctor. The hospital’s patient representativeor social worker will also help you with your questions and concernsabout hospital services.
If You Think You AreBeing Asked To Leave The Hospital Too Soon
Ask a hospital representativefor a written notice of explanation immediately, if you have notalready received one. This notice is called a “notice of noncoverage.”You must have this notice of noncoverage if you wish to exerciseyour right to request a review by the RRA.
The notice of noncoverage willstate whether your doctor or the RRA agrees with the hospital’sdecision that TRICARE should no longer pay for your hospital care.
•If the hospital and your doctoragree, the RRA does not review your case before a notice of noncoverageis issued. But the RRA will respond to your request for a reviewof your Notice of Noncoverage and seek your opinion. You cannotbe made to pay for your hospital care until the RRA makes its decisionif you request the review by noon of the first workdayafter you receive the notice of noncoverage.
•If the hospital and your doctordisagree, the hospital may request the RRA to review your case.If it does make such a request, the hospital is required to sendyou a notice to that effect. In this situation, the RRA must agreewith the hospital or the hospital cannot issue a notice of noncoverage.You may request that the RRA reconsider your case after you receivea notice of noncoverage, but since the RRA has already reviewedyour case once, you may have to pay for at least one day of hospitalcare before the RRA completes this reconsideration.
IF YOU DO NOT REQUEST A REVIEW,THE HOSPITAL MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY BEGINNINGWITH THE THIRD DAY AFTER YOU RECEIVE THE NOTICE OF NONCOVERAGE.THE HOSPITAL, HOWEVER, CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDESYOU WITH A NOTICE OF NONCOVERAGE.
How To Request A ReviewOf The Notice Of Noncoverage
If the notice of noncoveragestates that your physician agrees withthe hospital’s decision:
•You must make your requestfor review to the RRA by noon of the first work dayafter you receive the notice of noncoverage by contacting the RRAby phone or in writing.
•The RRA must ask for your viewsabout your case before making its decision. The RRA will inform youby phone and in writing of its decision on the review.
•If the RRA agrees with thenotice of noncoverage, you may be billed for all costs of your stay beginningat noon of the day after you receive theRRA’s decision.
•Thus, you will not be responsiblefor the cost of hospital care before you receive the RRA decision.
If the notice of noncoveragestates that the RRA agrees with the hospital’sdecision:
•You should make your requestfor reconsideration to the RRA immediatelyupon receipt of the notice of noncoverage by contacting the RRAin writing.
•The RRA can take up to threeworking days from receipt of your request to complete a review.The RRA will inform you in writing of its decision on the review.
•Since the RRA has already reviewedyour case once prior to the issuance of the notice of noncoverage,the hospital is permitted to begin billing you for the cost of yourstay beginning with the third calendar day after you receive yournotice of noncoverage, even if the RRA has not completedits review.
•Thus, if the RRA continuesto agree with the notice of noncoverage, you may haveto pay for at least one day of hospital care.
Note:The process described aboveis called “immediate review.” If you miss the deadline for this immediatereview while you are in the hospital, you may still request a reviewof the TRICARE decision to no longer pay for your care at any pointduring your hospital stay or after you have left the hospital. Thenotice of noncoverage will tell you how to request this review.
Post-Hospital Care
When your doctor determinesthat you no longer need all the specialized services provided ina hospital, but you still require medical care, he or she may dischargeyou to a skilled nursing facility or to home care. The dischargeplanner at the hospital will help arrange for the services you mayneed after your discharge. TRICARE and supplemental insurance policieshave limited coverage for skilled nursing facility care and homehealth care. Therefore, you should find out which services willor will not be covered and how payment will be made. Consult withyour doctor, hospital discharge planner, BeneficiaryCounseling and Assistance Coordinator (BCAC), patientrepresentative and your family in making preparations for care afteryou leave the hospital. Don’t hesitate to ask questions.
Questions involving billingor specific benefit coverage issues should be addressed to yourTRICARE claims processor which is:
Contractor's Address
Contractor's Toll-FreeTelephone Number
Acknowledgment Of Receipt
My signature only acknowledgesmy receipt of this message from (Name of Hospital) on (Date) and doesnot waive any of my rights to request a review or make me liablefor any payment.
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Signature Of Beneficiary OrPerson Acting On Behalf Of The Beneficiary
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Date Signed
